NCG551475_rescission_20220912

Weaver, Charles
From: Weaver, Charles
Sent: Monday, September 12, 2022 10:37 AM
To: 'Lee McDowell'
Cc: Kurtz, Cassidy
Subject: Rescission of NCG551475: Han -Dee Hugo's #96 / Wake County
Importance: High
The Division received your request to rescind the subject Certificate of Coverage (CoC) under General Permit
NCG550000. We do not object to this request.
NPDES CoC NCG551475 is hereby rescinded, effective immediately. This message is to close the permit file for the
Division, and for your records.
If in the future you wish to discharge wastewater to the State's surface waters, you must first apply for and receive a
new NPDES permit.
If you have any questions concerning this matter, simply reply to this message.
PLEASE NOTE: as part of the Division's conversion to paperless communication, this email is the only notification you will
be sent regarding the CoC rescission. No hard copy will be mailed.
Charles H. Weaver
Environmental Specialist
N.C. DEQ / Division of Water Resources
919-707-3616
[e-mail]
(mailing address) 1617 Mail Service Center, Raleigh, NC 27699-1617
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed
to third parties.
From: Lee McDowell<[e-mail]>
Sent: Friday, September 9, 2022 2:44 PM
To: Weaver, Charles <[e-mail]>
Subject: [External] Sampson Bladen: Han -Dee Hugo's #96
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Charles,
As discussed, we connected to water and sewer at our Han -Dee Hugo's facility located at 6927 Buffaloe Road, in March
of this year. The septic and water discharge treatment system was removed from the site, (septic tanks were crushed). I
have attached a copy of the Annual Permit fee invoice so you will have all the site information. I've also included the
water and sewer connection drawings, the encroachment permit and an invoice for the decommissioning of the old
system.
i

Please let me know if you need anything else from me.
Thank You
2

David Brantley and Sons Inc. 37 Pine Ridge Rd
252-478-3721 Zebulon, North Carolina
27597
United States
DA'VID BRAiNTLEY & SONS. INC.
Billed To Date of Issue Invoice Number
Sampson Bladen Oil Co 03/03/2022 0038921
PO Box 469
Attn:Accts Payable Dept Due Date
Clinton, North Carolina 04/02/2022
28329
United States Jql‘
Amount Due (USD)
$1,400.00
Description
Service
Han -Dee Hugo decommission DEQ discharge
Terms
5% late fee applied monthly
Rate Qty Line Total
$1,400.00 1 $1,400.00
Subtotal 1,400.00
Tax 0.00
Total 1,400.00
Amount Paid 0.00
Amount Due (USD) $1,400.00

December 21, 2020
County: Wake
Subject: Encroachment Contract
SR 2215
E051-092-20-01582
Samson Bladen Oil Company, Inc.
PO Box 469
Clinton, NC 28329
Dear Sir or Madam,
Attached for your files is a copy of Right of Way Encroachment Agreement, which has been properly
executed. This contract covers the following:
A 1" Tap on an Existing 16" Water Service
NO PAVEMENT CUTS ALLOWED
A PERFORMANCE AND INDEMNITY BOND IN THE VALUE OF $10,000.00 IS REQUIRED
AND SHALL BE POSTED WITH THE DISTRICT OFFICE PRIOR TO THE START OF WORK.
This encroachment is approved subject to the Standard and Special Provisions which are attached to and
made a part of the Encroachment Contract.
Sincerely,
A. N. Neidringhaus, P.E. (FL)
for J.R. Hopkins, PE, Division Engineer
JRH/ANN/rcb
cc: Ms. A. N. Neidringhaus (w/ orig)
City of Raleigh
Attachment
E051-092-20-01582 Page 9 of 16

Encroachment Special Provisions
1. NCDOT WORK ZONE TRAFFIC CONTROL QUALIFICATIONS AND TRAINING
PROGRAM:A. Effective July 1, 2010, all flagging operations within NCDOT Right of Way
require qualified and trained Work Zone Flaggers.B. Effective July 1, 2011, qualified and trained
Work Zone Traffic Control Supervisors will be required on Significant Projects.C. Training for this
certification is provided by NCDOT approved training sources and by private entities that have been
pre -approved to train themselves. If you have questions, contact our web site at
https://connect.ncdot.gov/projects/WZTC/Pages/default.aspx, or contact Joe Hummer, PhD, PE with
NCDOT Work Zone Traffic Control Unit at [phone] or [e-mail].
2. The encroaching party's construction contractor must submit the NCDOT Workforce Safety Plan for
Encroachment Activities: COVID-19 form to the District Engineer prior to construction.
3. Current and future state projects take precedence over this encroachment.
4. A 10,000.00 Performance and Indemnity Bond shall be executed and posted with the District Office at
4009 District Drive, Raleigh, North Carolina 27607, prior to beginning any work on the Right of Way.
When the project has been completed for a period of one year, upon written request by the Encroacher
to the District Office, a final inspection and review will be conducted by NCDOT, and if all work is
found satisfactory, the bond will be released.
5. This encroachment agreement only covers work within NCDOT Right -of -Way as shown on the attached
plans received in the District Office on November 18, 2020
6. Any personnel or equipment working within five feet of a travel lane shall require a full lane closure.
No lane of traffic shall be closed or restricted between the hours of 6:00 AM to 9:00 AM and 4:00 PM
to 7:00 PM Monday thru Friday, during any time of inclement weather, or upon District Engineer's
directive. Traffic shall be maintained at all times. Any violation of these hours will result in termination
of the Encroachment Agreement and liquidated damages in the amount of $2,000.00 per hour or any
portion thereof will be assessed by the District Engineers Office.
7. Notify the City of Raleigh before starting work.
8. The proposed utility shall be placed at a minimum depth of 3 feet and at a minimum distance of 3 feet
from the edge of pavement or back of curb for installation parallel to the roadway when plowing or
trenching. If crossing the roadway, the proposed utility is to be a minimum depth of 3 feet below the
roadway travel surface when using the conventional bore method. The proposed utility shall be
placed at a minimum depth of 3 feet and at a minimum distance of 3 feet from the edge of pavement or
back of curb for installation parallel to the roadway when using the directional bore method.
E051-092-20-01582 Page 10 of 16

9. Pavement cores made to expose existing utilities shall be made with a maximum 18" pavement core.
Pavement core locations shall not be placed in the wheel path whenever possible. Vacuum excavation
shall be utilized to expose underground utilities. Pavement cores shall be repaired within the same
working day. The pavement core shall be retained and reused to fill the core hole. The excavation
shall be backfilled and compacted with select material to the bottom of the existing pavement structure
or as indicated on the manufacturer's specifications. The retained core shall be placed in the hole and
secured with a waterproof, mechanical joint. All materials must be listed on the NCDOT Approved
Products List (APL) found here: https://apps.ncdot.gov/vendor/approvedproducts/ Prior to
completion, ensure road surface is clean.If the pavement core is damaged and cannot be re -used, the
core may be replaced with the surface mix, S9.5B. The asphalt patch shall match the thickness of the
existing asphalt or four inches, whichever is greater. Prior to completion, ensure road surface is clean.
If it becomes necessary for NCDOT to make any repairs associated with this encroachment, then the
encroaching party will be charged for all costs associated with the repair.
10. All pavement cuts must be sealed with NCDOT approved sealant to prevent future pavement separation
or cracking.
11. Any abandoned storm drainage pipe, driveway pipe, sewer line, gas line, force main, monitoring wells
and associated structures shall be grouted full. If choosing to remove, contact District Office at
[phone] prior to starting removal.
12. Blow -offs shall be directed away from the travel lane.
E051-092-20-01582 Page 11 of 16

Encroachment Standard Provisions
1. An executed copy of this encroachment agreement will be present at the construction site at all times
during construction. NCDOT reserves the right to stop all work unless evidence of approval can be
shown.
2. NCDOT reserves the right to revise, restrict, suspend and/or void this encroachment agreement if the
execution and/or operation of said permit is found to be a hazard to the traveling public.
3. This encroachment agreement only covers work within NCDOT Right -of -Way. The encroacher is
responsible for verifying all right of way. NCDOT does not guarantee the right of way on this road. If
the right of way was not obtained by the fee simple method, it is the responsibility of the encroacher to
obtain permission from the underlying property owner/owners.
Encroacher shall be responsible for obtaining all necessary permanent and/or temporary construction,
drainage, utility and/or sight distance easements. All Right of Way and easements necessary for
construction and maintenance shall be dedicated to NCDOT with proof of dedication furnished to the
District Engineer prior to beginning work.
4. The encroacher is responsible for any claim for damages brought by any property owner by reason of
the installation.
5. Notify the District Engineer's Office at [phone] or at 4009 District Drive, Raleigh, NC 27607,
prior to beginning and after completion of work.
6. The Encroacher shall notify the public, including all adjacent property owners and businesses, a
minimum of 2 weeks prior to beginning work.
7. Any and all changes noted in red on the plans shall be incorporated into and made part of the approved
permit.
8. The encroaching party shall comply with all applicable local, state and federal environmental
regulations, and shall obtain all necessary state and federal environmental permits, including but not
limited to, those related to sediment control, storm water, wetland, streams, endangered species, and
historical sites.
9. All materials and construction shall be in accordance with NCDOT standards and specifications,
including but not limited to, the NCDOT Standard Specifications for Roads and Structures 2012, the
NCDOT Roadway Standards Drawings, and NCDOT Policies and Procedures for Accommodating
Utilities on Highway Rights of Way.
10. The encroacher shall provide traffic control devices, lane closures, road closures, positive protection
and/or any other warning or positive protection devices necessary for the safety of road users during
construction and any subsequent maintenance. This shall be performed in conformance with the latest
NCDOT Roadway Standard Drawings and Standard Specifications for Roads and Structures and
Amendments or Supplements thereto. When there is no guidance provided in the Roadway Standard
Drawings or Specifications, comply with the Manual on Uniform Traffic Control Devices for Streets
and Highways and Amendments or Supplements thereto. No work shall be performed in the Right of
Way unless this requirement is satisfied. NCDOT reserves the right to require a written traffic control
plan for encroachment operations.
Sidewalk closures shall be installed as necessary. Pedestrian traffic shall be detoured around these
closures and shall be signed appropriately and in accordance with The American with Disabilities Act
Accessibility Guidelines.
E051-092-20-01582 Page 12 of 16

11. No parking or material storage shall be allowed along the shoulders of any NCDOT roadways.
12. Two-way traffic shall be maintained at all times.
13. No lane closures shall be permitted between the hours of 6:00 AM to 9:00 AM and 4:00 PM to 7:00
PM, Monday through Friday unless otherwise specified in the Special Provisions of this encroachment
agreement.
14. At the end of each working day, equipment shall be parked outside of the clear recovery zone in order
to avoid any obstruction to the travelling public. This clear recovery zone is measure from the edge of
the nearest travel lane.
15. Work shall not be performed on both sides of the road simultaneously within the same area.
16. Ingress and egress shall be maintained to all businesses and dwellings at all times.
17. All above ground appurtenances associated with the installation of the proposed utility shall be
located/relocated at or as near as possible to the right-of-way line and shall be set outside the Clear
Recovery Area as outlined by AASHTO.
18. All (cast -in -place and/or pre -cast) splice boxes, handholes, manholes, drainage structures and other
appurtenances within NCDOT Right of Way shall be of a NCDOT approved design for traffic bearing,
HS-20 loading, and shall be flush mounted. Manholes, handholes and vaults shall not be placed in the
ditch -line, side slopes of the ditch or in the pavement.
All frames, grates, rings, covers, etc. are to be manufactured in accordance with the requirements of
Section 106-1B - "Domestic Steel". Foreign castings are not approved for use within NCDOT Right of
Way.
19. Directional drilling methods have not been given Statewide approval for use on NCDOT right of way.
Under no condition shall jetting alone or wet boring with water of utility pipelines be allowed.
Directional boring using jetting with a Bentonite (or equivalent material) slurry is approved for this
installation at a minimum depth of ten (10) feet below the pavement surface {fifteen (15) feet below the
surface of partial and /or full control of access roads} and 5' below any ditch line. Any parallel
installation utilizing the directional boring method shall be made at a minimum depth of three (3) feet
(cover) below the ground surface and outside the theoretical 1:1 slope from the existing edge of
pavement where the parallel installation crosses a paved roadway. The tip of the drill string shall have a
cutter head. Detection wire shall be installed with non-ferrous material. Any changes shall be submitted
to the District Engineer prior to any consideration. For multiple conduit installations (including
perpendicular and parallel installations), install conduits with five (5) feet horizontal separation between
each conduit or install multiple conduits with a single duct. An overbore shall not be more than two (2)
inches greater than the diameter of the pipe, encasement, or duct. An overbore exceeding two (2) inches
greater than the diameter of the pipe, encasement, or duct will be considered if the encroachment
agreement includes a statement signed and sealed by a North Carolina Registered Professional Engineer
indicating that an overbore in excess of two (2) inches of the diameter of the pipe, encasement , or duct
will arch and no damage will be done to the pavement or subgrade. HDPE Pipe installed by directional
boring shall not be connected to existing pipe or fittings for one week from the time of installation to
allow tensional stresses to relax.
20. All crossings of state maintained routes shall be by bore only, unless otherwise stated in this
encroachment agreement.
21. Underground utilities may cross perpendicularly but not run longitudinally under the pavement.
E051-092-20-01582 Page 13 of 16

22. At points where the utility is placed under existing storm drainage, the trench will be backfilled with
concrete up to the outside diameter of the existing pipe in compliance with NCDOT standards.
23. The paving of this roadway shall be in accordance with the revised NCDOT 2012 Standard
Specifications, Sections 610, 1012 and 1020. The Contractor shall follow all procedures of the attached
Quality Management System (QMS) for asphalt pavement - Maintenance Version. The Contractor must
adhere to all testing requirements and quality control requirements specified. The Contractor shall
contact the NCDOT Division 5 QA Supervisor at [phone] prior to producing plant mix and
make the Supervisor aware that the mix is being produced for a future NCDOT road. Only NCDOT
approved mix designs will be acceptable. A quality control plan shall be submitted to the District
Engineer's Office prior to asphalt production. Use form QMS-MV 1 for the Quality Control Plan
submittal. Failing mixes and/or densities are subject to penalties including monetary payments or
removal and replacement.
24. Roadway certification reports sealed by a Professional Engineer shall be submitted to the North
Carolina Department of Transportation at 4009 District Drive, Raleigh, North Carolina, indicating the
following:
* Pavement thickness by type
* Pavement density, core and/or test locations
* Base thickness
* Base density
* Subgrade density
Test frequency and method shall be in conformance with the NCDOT "Materials and Tests" Manual.
Test must be performed by a Certified Technician including name and Certification number on report.
25. Any existing driveways, pavement, sidewalk, curb and gutter or drainage structures that are damaged
during construction shall be repaired to their original condition.
26. All meter bases and services shall be located/relocated at or as near as possible to the right-of-way line.
27. Pedestals shall be placed a maximum of one foot inside the Right of Way.
28. Fire Hydrants shall be of the break -away type. Hydrants shall be placed a maximum of one foot inside
the right of way in ditch sections or a minimum of 6 feet behind the curb in curb and gutter sections.
29. Hot boxes shall be located outside sight distance triangles and off of the NCDOT Right -of -Way.
30. When surface area in excess of one acre will be disturbed, the Encroacher shall submit a Sediment and
Erosion Control Plan which has been approved by the appropriate regulatory agency or authority prior
to beginning any work on the Right of Way. Failure to provide this information shall be grounds for
suspension of operations.
31. All erosion control devices and measures shall be constructed, installed, maintained, and removed by
the Encroacher in accordance with all applicable Federal, State, and Local laws, regulations,
ordinances, and policies. All earth areas shall be regraded and seeded in accordance with NCDOT
Standards Specifications for Roads and Structures 1995. Seeding rates per acre shall be the following:
* Year Round Mixture: 50# Pensacola Bahia Grass; 50# KY 31 Tall Fescue; 5# Centipede; 500# 10-
20-20 Fertilizer; 4000# Limestone;
* 2:1 Slopes Standard Mix: Use Year Round Mixture (Delete Centipede); Add 25# Service Lespedeza;
* If Using Crown Vetch on 2:1 Slope (September -May): Use Year Round Mixture; Add Crown Vetch
15 lbs./Ac.; (Delete Centipede and Bahia)
E051-092-20-01582 Page 14 of 16

32. The applicant is responsible for identifying project impacts to waters of the United States (wetlands,
intermittent streams, perennial streams and ponds) located within the NCDOT right-of-way. The
discharge of dredged or fill material into waters of the United States requires authorization from the
United States Army Corps of Engineers (USACE) and certification from the North Carolina Division of
Water Quality (NCDWQ). The applicant is required to obtain pertinent permits or certification from
these regulatory agencies if construction of the project impacts waters of the United States within the
NCDOT right-of-way. Additional information can be obtained by contacting the USACE or NCDWQ.
33. The applicant is responsible for avoiding impacts to federally protected species during project
construction. Bald eagle, Michaux's sumac, smooth coneflower, dwarf wedgemussel, harperella, red -
cockaded woodpecker and tar spinymussel are federally protected species that have been identified
within NCDOT right-of-way in Durham, Person, Granville, Wake, Franklin, Vance, and Warren
counties. Additional information can be obtained by contacting the North Carolina Natural Heritage
Program or the United States Fish and Wildlife Services.
34. The applicant is responsible for complying with the Neuse and Tar -Pamlico Riparian Buffer Rule as
regulated by the NCDWQ. The Rule regulates activity within a 50-foot buffer along perennial streams,
intermittent streams and ponds. Additional information can be obtained by contacting the NCDWQ.
35. Existing drainage patterns shall be maintained at all times throughout the proposed construction. The
encroacher shall keep the roadway clean of dirt and debris at all times throughout the duration of the
project.
36. The Division Traffic Engineer shall be notified at [phone] prior to any excavation within 500
feet of a signalized intersection or if there are existing NCDOT signs in or near the proposed work
zone. All traffic signal or detection cables must be located prior to excavation. All signal work and
traffic signs shall be coordinated with the Division Traffic Engineer. Costs to relocate, replace, or
repair NCDOT signs, signals, or associated equipment shall be the responsibility of the Encroacher.
37. All temporary and final pavement markings, reflective pavement markings and signage are the
responsibility of the Encroacher. All final pavement markings shall be thermoplastic. Any pavement
markings that are damaged or obliterated shall be restored at no expense to NCDOT.
38. All Traffic signs moved shall be reinstalled as soon as possible to meet NCDOT specifications.
39. Strict compliance with the Policies and Procedures for Accommodating Utilities on Highway Right of
Way manual shall be required.
40. It shall be the responsibility of the Encroacher to determine the location of other utilities within the
encroachment area. The Encroacher shall be responsible for notifying other utility owners and
providing protection and safeguards to prevent damage or interruption to existing facilities and to
maintain accessibility to existing utilities.
41. All earth areas disturbed shall be regraded and reseeded in accordance with Division of Highways
Standards and Specifications.
42. The Encroacher shall remove all trees, stumps and vegetative material from the right of way and dispose
of in a licensed landfill or disposal site.
43. Excavated material shall not be placed on the roadway at any time.
44. Trenching, bore pits and/or other excavations shall not be left open or unsafe overnight. The Contractor
shall comply with all OSHA requirements and provide a competent person on site to supervise
excavation at all times.
E051-092-20-01582 Page 15 of 16

45. All excavations inside the theoretical 1:1 slope from the existing edge of pavement to the bottom of the
nearest excavation wall should be made in accordance with the following conditions. Traffic should be
moved to a travel lane outside the limits of a theoretical one-to-one slope from the bottom of the nearest
trench wall to the pavement surface. Active excavation shoring, such as sheet piling, shall be installed.
The design of the shoring shall include the effects of traffic loads. The shoring system shall be designed
and sealed by an engineer registered in North Carolina. Trench boxes shall not be accepted as shoring.
The trench backfill material should meet the Statewide Borrow Criteria.
46. Excavated areas adjacent to pavement having more than a 2 inch drop shall be made safe with a 6:1 or
flatter slope and shall be designated by appropriate delineation during periods of construction inactivity,
including, but not limited to, night and weekend hours.
47. Backfill material is to be placed at a maximum of 6 inch loose layers and each layer thoroughly
compacted. All embankment backfill shall be compacted to 95% density and all subgrade to 100%
density in accordance with AASHTO T-99 as modified by NCDOT. They shall be signed by a
Professional Engineer and sent to the District Engineers Office at 4009 District Drive, Raleigh, NC
27607.
48. No commercial advertising shall be allowed within NCDOT Right of Way.
49. Guardrail shall be installed where warranted and in accordance with the guidelines shown in the 2012
Highway Design Branch Roadway Standard Drawings.
Guardrail removed or damaged during construction shall be replaced or repaired to their original
condition.
50. Poles shall be located/relocated at or as near as possible to the right-of-way line, shall be set outside the
Clear Recovery Area as outlined by AASHTO and outside sight distance triangles.
Poles located within guardrail sections shall be installed a minimum of 5 feet behind any guardrail.
When applicable, poles shall be placed behind sidewalk.
Any associated guy wires to ground anchors and stub poles shall not be placed between a pole and the
travel way and should be located outside the clear recovery area.
Minimum vertical clearance shall be 18' for aerial crossings over NCDOT roadways and 15'-6" for
installations parallel to the roadway.
51. Fire Hydrants shall be of the break -away type. Hydrants shall be placed a maximum of one foot inside
the right of way in ditch sections or a minimum of 6 feet behind the curb in curb and gutter sections.
52. Retaining walls or other vertical structures shall not be permitted inside NCDOT right of way.
E051-092-20-01582 Page 16 of 16

E051-092-20-01582
Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#
WORKFORCE SAFETY PLAN
FOR ENCROACHMENT ACTIVITIES: COVID-19
EFFORTS THE N.C. TRANSPORTATION INDUSTRY IS TAKING TO STOP THE SPREAD OF COVID-19
The North Carolina Department of Transportation (NCDOT) and their partners expect all parties involved in
the delivery of transportation projects to abide by the guidelines issued from the Centers for Disease
Control and Prevention (CDC) and the North Carolina Department of Health and Human Services (NCDHHS).
Response to COVID-19 is rapidly evolving; new information and guidelines may be issued from the CDC,
NCDHHS, or other state or federal agencies. NCDOT and their partners should review the current CDC and
NCDHHS guidance, including the resources listed at the end of this document, for up-to-date information
on how to respond to COVID-19. Additional guidelines may be issued by state or federal agencies that
should be followed in addition to the guidance included in this document.
Though certain Americans with Disabilities Act (ADA) requirements have been relaxed in response to the
pandemic, employers must still maintain all information about employee illness as a confidential medical
record in compliance with the ADA. If an employee is suspected of having or tests positive for COVID-19, it
is essential that management keep the identity of the employee and details related to the employee's
health confidential.
Below are precautions required by NCDOT and from encroaching parties and their contractors performing
construction within NCDOT Rights of Way. The term employee refers to any person on a job site within
NCDOT right of way for the purpose of constructing or inspecting the work related to construction of a
facility under an approved encroachment agreement and where that employee may or may not be under
employment by or under contract to NCDOT.
EMPLOYEE WELLNESS
• If an employee has not yet reported to work and develops any COVID-19 symptoms (i.e. fever,
coughing, or shortness of breath) — STAY HOME and immediately:
o Call a health care provider
o Self -Isolate
o Communicate with your supervisor
o Remain calm and follow all instructions from your health care provider
• Employees who appear to have acute respiratory illness symptoms (i.e. cough, shortness of breath)
upon arrival to work, or become sick during the day, should be separated from others and sent
home immediately. The potentially affected employees should immediately follow the steps
outlined above, which includes immediately contacting a health care provider.
• Should an employee show symptoms of acute respiratory illness or be diagnosed with COVID-19, all
other employees who have worked in close proximity to the affected employee during the last 14
Updated: 4/11/2020 Page 1

E051-092-20-01582
Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#•
days and all encroachment points of contact indicated at the end of this plan should be notified of
potential exposure to the disease without identifying the affected employee.
• Consideration should be given to employees at "High Risk" of severe illness from COVID-19, who,
per NCDHHS, include employees:
o Over 65 years of age, OR
o With underlying health conditions including heart disease, lung disease, or diabetes, OR
o With weakened immune system
• "High Risk" Employees should be given the opportunity to discuss alternate work
arrangements/duties with their employer or take leave according to their company policies.
• For guidance on confirmed positive tests for COVID-19, refer to the most recent version of the
"COVID-19 Guidance for Employees on Encroachment Job Sites within NCDOT Right of Way"
located on last page of this plan.
PERSONAL HYGIENE
• Clean hands often by washing with soap and water for 20 seconds. If soap and water are not
available and hands are not visibly dirty, an alcohol -based hand sanitizer that contains 60%-95%
alcohol may be used.
• Avoid touching your eyes, nose, mouth, or other parts of your face.
• Do not breathe, cough, or sneeze on another person or into the open air. Employees should cover
their noses and mouth with a tissue when coughing or sneezing (or an elbow or shoulder if no
tissue is available).
• A facemask for covering nose and mouth is encouraged on the job site.
• Appropriate gloves are encouraged while performing functions of the job.
CLEANING/DISINFECTING
• Wash stations and/or hand sanitizer are encouraged on each project site.
• Appropriate cleaning staff should clean frequently touched surfaces and objects with disinfectants
at a minimum of once per day.
o Office/buildings: door knobs, light switches, phones, computers/keyboards, copy machines,
elevator buttons, toilets, faucets, sinks, countertops, paper towel dispensers, desktops,
handrails, folders, vending machines, counters, tables, cabinets/knobs, etc.
o Shop Yard/Jobsite: vehicle/equipment door handles, keys, gear shifts, steering
wheel/operator controls and levers, fuel pump dispensers, touch points on machinery, etc.
o Electronic equipment: cell phones, computers, keyboards, etc.
• Appropriate cleaning staff should sanitize/disinfect facilities and work areas after persons
suspected/confirmed to have COVID-19 have been in the facility or work area.
Updated: 4/11/2020 Page 2

Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#•
E051-092-20-01582
o It is recommended to close off access to areas used by the ill persons and wait as long as
practical, 24 hours if possible, before beginning cleaning and disinfection to minimize
potential for exposure to respiratory droplets. Open outside doors and windows to increase
air circulation in the area if possible.
o Appropriate cleaning staff should clean and disinfect all areas used by the ill persons,
focusing especially on frequently touched surfaces.
GENERAL
• Increase communication measures between all parties regarding schedule, daily activities, etc. to
reduce/minimize worker exposure in accordance with but not limited to the requirements below.
• Minimize on -site personnel such as subcontractors, work crews, QC personnel, and inspection staff
to those required for that day's activities. If work is postponed or cancelled, immediately notify
appropriate parties.
• Practice "Social Distancing" whenever feasible. Social Distancing is designed to limit the spread of a
disease by reducing the opportunities for close contact between people. All personnel have the
responsibility to remind each other to stay 6 feet or more apart. Examples of Social Distancing
include:
o Reducing face-to-face exposure by using conference calls and video conferencing
■ If an in -person meeting is absolutely required and cannot be rescheduled or
attended remotely, the meeting is limited to a maximum of 10 people while
maintaining Social Distancing of 6 feet or more.
o Avoiding unnecessary travel
• Do not congregate at lunch or breaks. Bringing your lunch is encouraged.
• No communal coolers or drink stations are allowed. Supervisors should confirm with employees
prior to beginning work for appropriate hydration and nutrition availability to employees for the
duration of the employee's shift and without direct contact with others on the job site.
• First line of communication should be by phone, rather than in -person.
• Do not shake hands.
• Do not share iPads, tablets, pens, or clipboards for signing or any other purpose. Take pictures as
proof of attendance at meetings.
• Sharing of Personal Protective Equipment (PPE) is strictly prohibited.
• Vehicles, equipment, and tools
o Limit the number of people riding in a vehicle together.
o Wipe down and disinfect vehicles after each trip.
o As much as possible, do not share tools or equipment. If a tool or piece of equipment must
be shared, the parts of it that are touched should be sanitized between uses.
Updated: 4/11/2020 Page 3

Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#:
E051-092-20-01582
RETURN TO WORK
• The following criteria must be followed for an employee who is tested for Covid-19, or asked to
self -quarantine by health officials, or has contact with another employee with a positive test result
to return to work:
o at least a 14-day quarantine; OR
o release by a health care provider.
• In accordance with CDC guidance, the following criteria must be followed for an employee with a
positive test result to return to work:
o at least 14 days from positive test notification; AND
o at least 3 days (72 hours) have passed since recovery defined as resolution of fever without
the use of fever -reducing medications and improvement in respiratory symptoms (e.g.,
cough, shortness of breath); AND
o at least 7 days have passed since symptoms first appeared.
NCDOT may require certification of fitness to work from a health care provider.
ADDITIONAL RESOURCES
NCDOT and their partners should review the CDC and NCDHHS resources listed below for up-to-date
information on how to respond to COVID-19. Additional guidelines may be issued by state or federal
agencies that should be followed in addition to the guidelines included in this document.
• NCDHHS COVID-19 Resources:
o https://www.ncdhhs.gov/divisions/public-health/coronavirus-disease-2019-covid-19-
response-north-carolina
• NCOSHR Communicable Disease Emergency Policy
o https://oshr.nc.gov/policies-forms/workplace-wellness/communicable-disease-emergency
• OSHA Guidance on Preparing Workplaces for COVID-19
o https://www.osha.gov/Publications/OSHA3990.pdf
• CDC COVID-19 Resources:
o https://www.cdc.gov/coronavirus/2019-ncov/index.html
AGREEMENT
The encroaching party shall adhere to the requirements of this plan in order to continue work under their
approved encroachment agreement. Violations to this plan could result in the violating entity not being
allowed to continue work or all work ceasing as determined by the NCDOT District Engineer or Resident
Engineer.
PROJECT POINTS OF CONTACT
Updated: 4/11/2020 Page 4

Workforce Safety Plan: COVID-19
NCDOT
NCDOT Encroachment ID#:
Ent o ching Party (Primary Contact)
Name: 4 /t Name:
ames Midge e
Phone : [phone]
Phone #:
919-733-321:1
Primary Contractor to Encroaching Party
(Point of Contact)
Name:
Phone #:
Updated: 4/11/2020 Page 5

Updated: April 11, 2020
COVID-19 Guidance for Employees on Encroachment Job sites within NCDOT Right of Way
Relationship to
Confirmed
POSITIVE Test
CONTACT GROUP
What YOU Should Do
What your CREW Should Do
Exposure within 6' and longer than 10 minutes ` Id Do
No exposure withinn 66' ' anand longer than 10 minutes I
What PROJECT SITE Personnel
Employee
You
Ak
w
Notify your supervisor
Self -quarantine for 14 days
Advise of POSITIVE test without identifying
the affected employee*
Directly exposed crew self -quarantine for 14
days
Continue hygiene & disinfecting measures
Advise of POSITIVE test without identifying the
affected employee*
Site personnel without direct contact may
continue onsite work or follow their company
policy
Continue hygiene & disinfecting measures
Direct Contact
Interaction with an
infected person
within 6' and longer
than 10 minutes
You
Ak
III
I-Ta LTA
Self -quarantine for 14 days
Advise of POSITIVE test without identifying
the affected employee*
Crew may continue onsite work or follow
their company policy
Continue hygiene & disinfecting measures
Advise of POSITIVE test *
Continue hygiene & disinfecting measures
Secondary
Contact
Two or more
Persons
Removed from
Contact
You
Ak Ak Ak
VP I.�
LIA L
You may continue onsite work or follow
your company policy
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
You
Ak Ak Ak Ak
LTA -T-
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
*Notification
Protocol
(Comply with HIPAA
& ADA
confidentiality
requirements)
NCDOT employee / agent tests
POSITIVE
NCDOT District Engineer/Resident Engineer notifies Encroaching Party's primary point of contact and Contractor Point of
Contact, CDC and, if Resident Engineer has oversight for the job site, FHWA any Consultant Firms working for NCDOT
Encroaching party representative notifies other Contractors, Sub -Contractors and Suppliers with exposed Employees
Encroaching Party or Contract crew
member on job site tests POSITIVE
Encroaching party representative or Contractor point of contact notifies appropriate NCDOT District Engineer or Resident
Engineer and all other Contractors, Sub -Contractors and Suppliers with exposed Employees
NCDOT notifies CDC, and as appropriate, FHWA and any Consultant Firms working for NCDOT
Joint Workforce Safety Plan: COVID-19 Page 6

ROUTE _SR 2215
STATE OF NORTH CAROLINA
PROJECT 6927 Buffaloe Rd COUNTY OF Wake
DEPARTMENT OF TRANSPORTATION
-AND-
Samson Bladen Oil Company, Inc.
P.O. Box 469, Clinton NC 28329
-AND-
City of Raleigh __
P.O. Box 590, Raleigh, NC 27605
THREE PARTY RIGHT OF WAY
ENCROACHMENT AGREEMENT ON
PRIMARY AND SECONDARY SYSTEM
THIS AGREEMENT, made and entered into this the 7 _ day ofJanuary 20 �L , by and between the Department
of Transportation, party of the first part; and Samson Bladen Oil Company, Inc.
party of the second part; and The City of Raleigh
party of the third part,
WITNESSETH
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) SR 2215 fBuffaloe Road) , located +/-60 west of the intersection of SR 2215 and
SR 2931 Pine Dr) toward SR 2925 (Elizabeth Dr).
with the construction and/or erection of: A 1" tap on an existing 16" water line and a 1" water service as shown on the attached
Plans titled: "SKETCH PLAN for Sampson Bladen Oil Company, Inc. prepared by
The Site croup, PLLC.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the party of
the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment within the limits of the
right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second part the right
and privilege to make this encroachment as shown on attached plan sheet(s), specifications and special provisions which are
made a part hereof upon the following conditions, to wit:
That the installation, operation, and maintenance of the above described facility will be accomplished in accordance with the party of
the first part's latest POLICIES AND PROCEDURES FOR ACCOMMODATING UTILITIES ON HIGHWAY RIGHTS -OF -WAY, and such
revisions and amendments thereto as may be in effect at the date of this agreement. Information as to these policies and procedures
may be obtained from the Division Engineer or State Utility Agent of the party of the first part.
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe and proper
condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper maintenance
thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways and structures
necessary due to installation and existence of the facilities of the party of the second part, and if at any time the party of the first part shall
require the removal of or changes in the location of the said facilities, that the said party of the second part binds himself, his successors
and assigns, to promptly remove or alter the said facilities, in order to conform to the said requirement, without any cost to the party of the
first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal lights,
flagmen and other warning devices for the protection of traffic in conformance with the latest -Manual on Uniform Traffic Control Devices
for Streets and Highways and Amendments or Supplements thereto. Information as to the above rules and regulations may be obtained
from the Division Engineer of the party of the first.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages and
claims for damage that may arise by reason of the installation and maintenance of this encroachment.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of the
Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution during
construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and regulations
of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and with ordinances
and regulations of various counties, municipalities and other official agencies relating to pollution prevention and control. When any
installation or maintenance operation disturbs the ground surface and existing ground cover, the party of the second part agrees to
remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division Engineer of the party of the
first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary by the
Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the construction site, at all times during construction, a copy of this
agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all work unless
evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the second part
agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has been completed.
Unless specifically requested by the party of the first part, written notice of completion of work on highway projects under construction will
not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part, the party of the first part reserves
the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to the party of the
first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein is not
begun within one (1) year from the date of authorization by the party of the first part unless written waiver is secured by the party of the
second nart from the party of tha first part
FORM R/W 16.6
Rev. July 1, 1977

During the performance of this contract, the second party, for itself, its assignees and successors in interest (hereinafter referred to as
the "contractor"), agrees as follows:
a. Compliance with Regulations: The contractor shall comply with the Regulations relative to nondiscrimination in Federally -
assisted programs of the U. S. Department of Transportation, Title 49, Code of Federal Regulations, Part 21, as they may be
amended from time to time, (hereinafter referred to as the Regulations), which are herein incorporated by reference and
made a part of this contract.
b. Nondiscrimination. The contractor, with regard to the work performed by it during the contract, shall not discriminate on the
grounds of race, color, or national origin in the selection and retention of subcontractors, including procurements of materials
and leases of equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by
Section 21.5 of the Regulations, including employment practices when the contract covers a program set forth in Appendix B
of the Regulations.
c. Solicitations for Subcontracts, including Procurements of Materials and Eguipment: In all solicitations either by competitive
bidding or negotiation made by the contractor for work to be performed under a subcontract, including procurements of
materials or leases of equipment, each potential subcontractor or supplier shall be notified by the contractor of the
contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race, color,
or national origin.
d. Information and Reports: The contractor shall provide all information and reports required by the Regulations, or directives
issued pursuant thereto, and shall permit access to its books, records, accounts, other sources of information, and its
facilities as may be determined by the Department of Transportation or the Federal Highway Administration to be pertinent to
ascertain compliance with such Regulations or directives. Where any information required of a contractor is in the exclusive
possession of another who fails or refuses to furnish this information, the contractor shall so certify to the Department of
Transportation, or the Federal Highway Administration as appropriate, and shall set forth what efforts it has made to obtain
the information.
e. Sanctions for Noncompliance: In the event of the contractor's noncompliance with the nondiscrimination provisions of this
contract, the Department of Transportation shall impose such contract sanctions as it or the Federal Highway Administration
may determine to be appropriate, including, but not limited to,
(1) withholding of payments to the contractor under the contract until the contractor complies, and/or
(2) cancellation, termination or suspension of the contract, in whole or in part.
f. Incormoration of Provisions: The contractor shall include the provisions of paragraphs "a" through "f' in every subcontract,
including procurements of materials and leases of equipment, unless exempt by the Regulations, or directives issued
pursuant thereto. The contractor shall take such action with respect to any subcontract or procurement as the Department
of Transportation or the Federal Highway Administration may direct as a means of enforcing such provisions including
sanctions for noncompliance: Provided, however, that, in the event a contractor becomes involved in, or is threatened with,
litigation with a subcontractor or supplier as a result of such direction, the contractor may request the Department of
Transportation to enter into such litigation to protect the interests of the State, and, in addition, the contractor may request
the United States to enter into such litigation to protect the interests of the United States.
That when title to the subject that constitutes the aforesaid encroachment passes from the party of the second
part and vests in the party of the third part, the party of the third part agrees to assume all responsibilities and rights and to
perform all obligations as agreed to herein by the party of the second part.
R/W (166) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R/W (166) incorporating all revisions to date.
IN WITNESS WHEREOF, each of the parties to this agreement has caused the same to be executed the day and
year first above written.
WITNESS:
DEPARTMENT OF TRANSPORTATION
DIVISION NGINEER
K Lee. w e1t
336ck -OrctI+s.c tr�kC;fcLe
li�4lei � NC 2..7
WITNESS:
ga G s�utk
Gail Smith (Nov 11, 202017:56 EST)
Gail Smith, City Clerk
R ck.1 y ( 1� c. Z 7 G o 7
\1 Second Party
/V/hae/Moome
Michael Moore (Nov 5, 2020 17:13 EST
Michael Moore, Director of Transportation
City of Raleigh City of Raleigh
Third Party

EX. SEPTI
j(TO BE ABANDONED)
CORE DRILL & CONNECT TO EX. MHO
SET NEW INVERT AT SHELF OF MH
EX. GRA yE-L
NEW 4" SAN SEWER SERVICE
(+80 LF © 2% MIN)
NEvC..
�tt X.
EX. PAVEMENT
I
I
, --__,
L ) I EW 1' RPZ: FEBCO 1 F 825Y RP QT
4.,l `I , / (OR CITY APPROV EQUAL)
-- _ l j
T—>n`_
BVP�+' n� / ` `I e'ga� 1TAP UEX. 0 16ETD.RI.01 L
(sR 2.—; !LOAD // 1 & INSTALL
1" 'ORP COCnK
������" w(ln, FH
EXISTING :LF (APPROX LOCATION)
DISCONNEC ROM BUILDING PLUMBIN
NEC CITY
SUPPLY Ns T0A00)
CITYWATER
TERMINATE W TER SERVICE OUTSIDE BUILDING
[COORDINATE CONNECTION TO EXIST PLUMBING
W/ BASIC P MBING: [phone]]
CONNECTION TO EX. BLDG PLBG
AT EXIST HYDROPNEUMATIC TANK
AND DISCONNECTION OF EXIST WELL
BY PLUMBING CONTRACTOR —SEPARATE
PERMIT REQUIRED
END CONSTRUCTIO SIGN
NEW 1' W.V.
NEW 1'
CURB STOP
EX 16" DI W/L
NEW 1" WATER SERVICE
(- 320 LF)
SKINNY DR
(+10' C.
WOR ZONE
(W NOT L
City of Raleigh Public Utilities
Cross Connection Program
Certificate of Compliance Application
New Construction
pte, 10/26/2020
PINT: 1746-03-4839mu* Prom ldemm:awnNwna.,..nbe omen wakesae.Red
Aamesa: 6927 Buffaloe Rd.., Raleigh, NC 27616
Street Address (Sheaf new construdbn) City state
Daytime Phone Number [phone] Lee.Mcoowall®sampsonbleden.com
Enell:
Office Use Only
Date Ap$lratlan Received:
3J20 7L
yesgt NOD
Can Hartley
Connection Coordinator
Containment Assembly: A baekllnw assembly, Installed at the polo of sea...1We between the publIc water supply a. Px.xate
service or private distrlbutlon system or at the point of metering.
Minimum requirements: Containment assemblMs must be Installed within SW linear feet of piping from the most downstream
edge ofthe meter boxor ROW end be on the ASSE and USC approval Inc Please see Appendix A: Guidelines and Requirements for
the Cross Connection Program for further Installation guidelines.
Water Service
(Domestic, Irrigation,
Fire, or Prlwte
Dixdboion System)
Type of Back5ow: Reduced
Pressure tonelRP7), Reduced
Pressure Detector Assembly
(RPM), Double Cho. (DC). or
Double Check Detector
Model of Containment
&wallow
Sired Service
ORke Use only
4ppmvaloflaat10n,
Type, and Model
Danwrx
Rsssembly(DC04)
P1W.azo»(PM
HMCo f is BMMPTRR .
f
ProAsslonsl er
I ordamad melee anuinmw uuknow assemblieseMist be installed mp.m Any uterrne
to Raleigh City Cede Anise D:Wese,Ouli,y Protection end ApApppedi0MS
RE ldl, eannw.mn%Orem, P.E.'�m•um eonninmwweglw,.m��,mma�,: as loft
EdwinF. Sconfienza, P.E. (911�35 4787
1111 Oberllin Rd, Suite 200 Raleligh
slwRu.
NC 27605
Sloe 7d1Cade
10/26/2020
CURB STOP BOX
ROADWAY %\`
SIDEWALK
p� aaec11).
TOP OF VALVE NEEDS
TO BE 12" BENEATH
TOP OF METER BOX LID.
LOCKABLE VALVE
3" #67 STONE
BACKFLL, TAMPED
IN 6" UFTS
45°
SEE DETAIL W-25
FOR METER BOX
�1 II I 111��
�1 `PLUG LOCK
: .i'�t.. r
i
'Y.✓`R��//i.
BRASS CURB STOP 3/4" OR I"TYPE "K'
SOFT COPPER PIPE,
CONCRETE BR)CK NO JOINTS OR
UNDER CORPORATION COUPLINGS
COCK FOR SUPPORT
CORPORATION COCK
SITE DATA SUMMARY
PROJECT NAME:
PIN:
SITE ADDRESS:
JURISDICTION:
ZONING:
OVERLAY DISTRICT:
WATERSHED:
RIVER BASIN:
TOTAL EXISTING ACREAGE:
CURRENT USE:
PROPOSED USE:
EXISTING BUILDING AREA:
TOTAL BUILDING AREA:
EXISTING IMPERVIOUS AREA:
PROPOSED NEW IMPERVIOUS AREA:
EXISTING GRAVEL AREA:
EXISTING PAVEMENT AREA:
DUAL CHECK VALVE
BACKFLOW PRE-
VENTION DEVICE
STANDARD 3/4"
OR 1" SERVICE
SIZE
3' TYPE K SOFT COPPER,
CRIMP SERVICE AT END
SET BOX ON CONCRETE BLOCKS
5/3"X 12" COPPER
SETTER METER YOKE
aS� NOTES:
_p I . WATER METER AS MANUFACTURED BY SENSUS, OR SCHLUMBERGER.
(t 0 2. DIRECT TAP ALLOWED ON MAINS NO LARGER THAN 16" LINE,
3. METER BOX TO BE LOCATED IN R/W ADJACENT TO PROPERTY OR IN APPROVED
EASEMENT ADJACENT TO R/w.
"3 4. WHEN THE GRADE CHANGES ON EXISTING SERVICES, A COPPER RESETTER CAN BE
Cep USED TO ADJUST TO GRADE. COPPER RESETTERS ARE PROHIBITED ON NEW SERVICES.
5. CURB STOP BOX SHALL HAVE PLUG STYLE LID WITH PENTAGON BOLT. I -1/4" STEEL
UPPER SECTION, AND ARCH STYLE BASE. STEEL STATIONARY ROD TO BE PROVIDED FOR
CURB STOP OPERATION.
UTILITY LEGEND
PROPOSED STORM PIPE
EXISTING STORM PIPE
PROPOSED SANITARY SEWER
EXISTING SANITARY SEWER
PROPOSED WATER LINE
EXISTING WATER LINE
- PROPOSED CURB INLET
❑ EXIST. CURB INLET/YARD INLET
III PROPOSED FES
• MH 1'R5POSED YARD INLET
O PROPOSED SANITARY MANHOLE
EXISTING SANITARY MANHOLE
0 C.O. PROPOSED SANITARY CLEAN OUT
0 C.O. EXISTING SANITARY CLEAN OUT
® PROPOSED WATER METER
® EXISTING WATER METER
N PROPOSED WATER VALVE
NI EXISTING GATE VALVE
N1 PROPOSED BLOW OFF
I EXISTING BLOW OFF
4— PROPOSED FIRE HYDRANT
IIIIIIII-- 0 STREET LIGHT
GENERAL NOTES
SAMSON BLADEN OIL COMPANY
1746-03-4839
6927 BUFFALOE RD. RALEIGH, NC
CITY OF RALEIGH
IX-3
SHOD-1
FALLS LAKE
NEUSE
1.85 AC./80,586 SF.
RETAIL SALES (VEHICLE FUEL SALES)
RETAIL SALES (VEHICLE FUEL SALES)
4,100 SF.
4,100 SF.
53,084 SF./ 1.22 AC.
0 SF./ 0 AC.
28,917 SF./.66 AC.
19,715 SF./.45 AC.
1. ALL MATERIALS AND METHODS OF CONSTRUCTION SHALL BE IN
ACCORDANCE WITH THE CITY OF RALEIGH AND THE STATE OF NORTH
CAROLINA STANDARDS AND SPECIFICATIONS.
2. CONTRACTOR SHALL HAVE NORTH CAROLINA ONE CALL (811) LOCATE
ALL EXISTING UTIUTIES PRIOR TO BEGINNING CONSTRUCTION.
3. CONTRACTOR SHALL VERIFY THE LOCATION AND DEPTH OF ALL EXISTING
UTILITIES AND NOTIFY THE ENGINEER OF ANY DISCREPANCIES OR
CONFLICTS PRIOR TO BEGINNING CONSTRUCTION.
4. BOUNDARY AND PLANIMETRIC INFORMATION IS TAKEN FROM WAKE
COUNTY GIS SUPPLEMENTED WITH INFORMATION FROM CITY OF RALEIGH
PUBLIC UTILITES WITH LIMITED FIELD VERIFICATION.
ALL CONSTRUCTION SHALL CONFORM TO A.D.A. STANDARDS.
NORTH
SKETCH
P LAN
SCALE: 1 " = 40'
(DRAWING SCALED FOR 11X17 INCH PLOTS)
0 40 80 120 160
CERT. NO
353
4<EIGH
NC ENGINEERING
LICENSE NO, P-0803
ARCHITECTS
CIVIL ENGINEERS • LANDSCAPE
0
Lg
WATER & SEWER SERVICE CONNECTION PLAN
JFF
Drawn
By
Checked
By
RLA
EFS
DATE:
10/29/20
REVISED:
1\18 NOV 2020
PERMIT
DOCUMENTS
SKETCH
PLAN
2 Job
Code
SBBWS
Dwg /No
S'\
1.0

ILL
J
_ I
I
N
T 11 f Jgt
�
BUFFALO — 1 / ...
o
(sR 2215) AD {�' \
I
I
0 0 I
I
I
I
l I I I
�
C] I I I
—_ I I ,'
V J 1
_ / I
/ � I
II
END CONSTRUCTION SIGN
SKINNY —DRUM BARRICADE
(+10' 0.C. IN WORK ZONE)
WORK ZONE ON SHOULDER OF ROAD
(W/L NOT UNDER PAVEMENT)
0
5N
f '
�N -15 POUND
BALLAST MIN.
SKINNY -DRUM
BARRICADE(S)
SKINNY —DRUM BARRICADE
(+25' 0.C. TO OFF RAMP [+450']) /
4
\0
0
I /
I I
/
/ /
/
/
"ROAD WORK AHEAD" SIGNS
GENERAL NOTES
1. ALL MATERIALS AND METHODS OF CONSTRUCTION SHALL BE IN ACCORDANCE WITH THE
CITY OF RALEIGH AND THE STATE OF NORTH CAROLINA STANDARDS AND SPECIFICATIONS.
2. CONTRACTOR SHALL HAVE NORTH CAROLINA ONE CALL (811) LOCATE ALL EXISTING
UTILITIES PRIOR TO BEGINNING CONSTRUCTION.
3. CONTRACTOR SHALL VERIFY THE LOCATION AND DEPTH OF ALL EXISTING UTILITIES AND
NOTIFY THE ENGINEER OF ANY DISCREPANCIES OR CONFLICTS PRIOR TO BEGINNING
CONSTRUCTION.
4. BOUNDARY AND PLANIMETRIC INFORMATION IS TAKEN FROM WAKE COUNTY GIS
SUPPLEMENTED WITH INFORMATION FROM CITY OF RALEIGH PUBLIC UTILITES WITH LIMITED
FIELD VERIFICATION.
ALL CONSTRUCTION SHALL CONFORM TO A.O.A. STANDARDS.
NORTH
TRAFFIC
CONTROL PLAN
SCALE: 1" = 50'
(DRAWING SCALED FOR 11X17 INCH PLOTS)
0 50 100 150 200
NC ENGINEERING
LICENSE NO. P-0803
ARCHITECTS
El
0
0
WATER & SEWER SERVICE CONNECTION PLAN
U
Z
Z
a_
2
0
0
J_
0
Z
W
0
J
m
z
0
2
BUFFALOE RD.
co
RALEIGH, NORTH CAROLINA 27616
Drawn RLA
By
Checked EFS
DATE:
11/18/20
PERMIT
DOCUMENTS
TRAFFIC
CONTROL
PLAN
Job
SBBWS
Dwg/No
S'
2.0

EX. SERVICE & SEPTI
j(TO BE ABANDONED)
CORE DRILL & CONNECT TO EX. MHO
SET NEW INVERT AT SHELF OF MH
NEW 4" SAN SEWER SERVICE
(+80 LF ® 2% MIN)
REPLACE EX. 500 GAL
GREASE TRAP WITH NEW
1500 GALLON GREASE TRAP
EX. PAVEMENT
EX 16" DI W/L
EXISTING :LF (APPROX LOCATION)
DISCONNEC ROM BUILDING PLUMBIN
(CROSS C SUPPLY Nr TNEC 0A£D) CITY WATER
City of Raleigh Public Utilities
Crass Connection Program
Certificate of Compliance Application
New Construction
pgia. 1746.034839 ,ro.P„p0aneetwx0a WG,rlema
Address: 8927 Buffaloo Rd.., Raleigh, NC 27818
spenaderermeat neoNenneeai) my
a.Nutley
a CanPeman coordinator
03111ma Phane Nun6a (9/9)847-7850 Finan: Lee.Moowrml®aommeensd.n.oAn
Caehlbmempmmbip Abarall0W anembN, Ind -ailed at the point olseparalbn beNmn the pubRtwaln supply and a private
zer000 orpMate dhnlbuean tyaem or atthe point of metering
Minimum raNmmentn Cmilelnmmt aasemblier most br ImNRedWdhIn Sp' linear fan alpiping from the mon dawm ream
edge al the meta bva r ROW and bei on the ME and USC apprmealhtt, Nem tee Appmeir A GuideMn and NeNiroman“
the Cress Cania0Oon Program far further inarlhllan NMellnn.
Waimsen
(panal4 Iniptlolh
Ntt, or Private
Martbutian5 N,4
TypearaacMow; Reduced
Presnrezonn(nn }, Reduced
Pressureoeleefpfnpnbiy
wogl, Double Mak MCk w
Double Cheek owecter
Meted* MOM
Meal d0rhlmenl
Sallow
57adaedw
0lla8MOeiy
Appeal of rypry
TYPO end Model
.scan
Rwieunaa>eb.pal7
190011PROSYWRP .
P
erwrgrls
iMrYlrallsolriWrrmabba♦leboRlr®rrrarlbM+tRO.R PaR*.q.O.....AgaarW
Rolialloraenaldrrarmhdlweimermalaa CkarOs hapo*P yepai.Avab�trlrrrbPraYlesMelbarlrYa rr�'ey
Edwin F. SCOnfanza, P.E
Ed Sconflen2A
From
Sent
To:
Cc:
Subject
Attachments
01888 4787
NC 27806
cue Aro .
10/2012020
one
orb: urroaao r e waroaease
anaaan.,10 1rne,
,awd.e
Calverley, Stephen .Slepllen.00o0) y0raleighnogov.
Monday, April 24. 2021 908 AM
Ed konnenrs
7OG: Calverley. Stephen
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Raleigh Water Fats 011 and Grease offers no objection to Sampson Bladen 0(1 Co. located et 6927 Buffalo@ Road Raleigh
RC installing a future use,/ use 1500 gallon grease Interceptor. The grease interceptor shall conform to S40,41 and
25 detail. Any future tenants shall be required to submit approval before connecting to the Interceptor. To seek
approval to connect to a new grease interceptor you must submit a copy of the plumbing plans and a completed sizing
calculator attached. The plumbing plans shall Include a plumbing fixture schedule and details showing the installed
fixtures connected to the grease waste water line and the proposed grease Interceptor. Please submit your completed
documents to foa8ralelahnc.aov
Thank you,
Stephen Caivedey
Utilities Analyst
Oty of Raleigh
Public UtilNes Department
hb, Oil and Grease
Raleigh water
Po Box 590
Raleigh, NC 2390
(p)9149942304(34(m)914G043227
(n 9149964871
Ratak ncaoa
UTILITY LEGEND
—ixon PROPOSED STORM PIPE
EXISTING STORM PIPE
PROPOSED SANITARY SEWER
EXISTING SANITARY SEWER
a PROPOSED WATER LINE
a EXISTING WATER LINE
- PROPOSED CURB INLET
❑ EXIST. CURB INLET/YARD INLET
PROPOSED FES
• MH1P126POSED YARD INLET
PROPOSED SANITARY MANHOLE
EXISTING SANITARY MANHOLE
0 C.O. PROPOSED SANITARY CLEAN OUT
0 C.O. EXISTING SANITARY CLEAN OUT
® PROPOSED WATER METER
® EXISTING WATER METER
N PROPOSED WATER VALVE
N EXISTING GATE VALVE
NO PROPOSED BLOW OFF
Xie EXISTING BLOW OFF
4— PROPOSED FIRE HYDRANT
=—O STREET LIGHT
SITE DATA SUMMARY
PROJECT NAME:
PIN:
SITE ADDRESS:
JURISDICTION:
ZONING:
OVERLAY DISTRICT:
WATERSHED:
RIVER BASIN:
TOTAL EXISTING ACREAGE:
CURRENT USE:
PROPOSED USE:
EXISTING BUILDING AREA:
TOTAL BUILDING AREA:
EXISTING IMPERVIOUS AREA:
PROPOSED NEW IMPERVIOUS AREA:
EXISTING GRAVEL AREA:
EXISTING PAVEMENT AREA:
GENERAL NOTES
SAMSON BLADEN OIL COMPANY
1746-03-4839
6927 BUFFALOE RD. RALEIGH, NC
CITY OF RALEIGH
IX-3
SHOD-1
FALLS LAKE
NEUSE
1.85 AC./80,586 SF.
RETAIL SALES (VEHICLE FUEL SALES)
RETAIL SALES (VEHICLE FUEL SALES)
4,100 SF.
4,100 SF.
53,084 SF./ 1.22 AC.
0 SF./ 0 AC.
28,917 SF./.66 AC.
19,715 SF./.45 AC.
1. ALL MATERIALS AND METHODS OF CONSTRUCTION SHALL BE IN
ACCORDANCE WITH THE CITY OF RALEIGH AND THE STATE OF NORTH
CAROLINA STANDARDS AND SPECIFICATIONS.
2. CONTRACTOR SHALL HAVE NORTH CAROLINA ONE CALL (811) LOCATE
ALL EXISTING UTILITIES PRIOR TO BEGINNING CONSTRUCTION.
3. CONTRACTOR SHALL VERIFY THE LOCATION AND DEPTH OF ALL EXISTING
UTILITIES AND NOTIFY THE ENGINEER OF ANY DISCREPANCIES OR
CONFLICTS PRIOR TO BEGINNING CONSTRUCTION.
4. BOUNDARY AND PLANIMETRIC INFORMATION IS TAKEN FROM WAKE
COUNTY GIS SUPPLEMENTED WITH INFORMATION FROM CITY OF RALEIGH
PUBLIC UTILITES WITH LIMITED FIELD VERIFICATION.
5. ALL CONSTRUCTION SHALL CONFORM TO A.D.A. STANDARDS.
DRAWINGS INDEX:
SK 1.0 SKETCH PLAN
SK 2.0 TRAFFIC CONTROL PLAN
SK 3.0 DETAILS
NORTH
SKETCH
P LAN
SCALE: 1 ter = 40'
(DRAWING SCALED FOR 11X17 INCH PLOTS)
120 160
CERT. NO
353
4bFTw CARC
4LEIGH
NC ENGINEERING
LICENSE NO. P-0803
ARCHITECTS
CIVIL ENGINEERS • LANDSCAPE
WATER & SEWER SERVICE CONNECTION PLAN
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BUFFALOS RD.
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RALEIGH, NORTH CAROLINA 27616
Drawn
By
Checked
By
RLA
EFS
DATE:
10/29/20
REVISED:
\18 NOV 2020
2Q23 APR 2021
3L27 APR 2021
PERMIT
DOCUMENTS
SKETCH
PLAN
Job
Code
SBBWS
Dwg /No
S'\
1.0

H \The SITE Groun\Proierts\SBBWS\Dwn\SBBWS SiteBese (Iwo. 4/27/7021 9:54:49 AM
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0
MOD
OM
PRECAST BAFFLE
4" THICK
ADJUSTED TO
FINISHED GRADE
8" W/ 6/5/4"
BOOT
SOLID RING & COVER,
OPEN
OUTLET
NOTES:
1. REINFORCEMENT: H-20 BRIDGE
LOADING (TRAFFIC RATED)
2. CONCRETE: 4000 PSI 028 DAYS
3. EARTHCOVER: 0' TO 5' MAX.
LENGTH
CITY OF RALEIGH
DEPARTMENT OF PUBLIC UTILITIES
1000 GALLON GREASE INTERCEPTOR
DWG. NO
S- 40
REVISIONS
RRH
ABB
DATE REVISIONS
3/9/00 D.H.L.
3/19/04
DATE
6/18/08
LOCALLY AVAILABLE SIZES
INTERCEPTORS
SEPARATORS
CAPACITY (GAL.)
CAPACITY (GAL.)
300
1000
550
1200
750
1600
1000
1200
1500
2000
2500
3000
4000
5000
6000
8000
NOTES:
1. BAFFLE WALL LOCATED AT A DISTANCE FROM INLET WALL 2/3 TO 3/4 OF THE TOTAL LENGTH
OF THE INTERCEPTOR OR SEPARATOR AS SHOWN ON DETAIL 5-40.
BAFFLE WALLS LOCATED AT A DISTANCE APPROXIMATELY OF Y3 OF THE TOTAL LENGTH OF THE
SEPARATOR AS SHOWN ON DETAIL S-40.01.
2. EACH INTERCEPTOR OR SEPARATOR SHALL HAVE INLET AND OUTLET TEES. THE OUTLET TEE
SHALL EXTEND 505 INTO THE LIQUID DEPTH. THE INLET TEE SHALL EXTEND 25% INTO THE
LIQUID DEPTH. INLET AND OUTLET TEES MUST BE OPEN TO ALLOW THE COLLECTION OF F.O.G.
SAMPLE.
3. ACESS OPENINGS OVER EACH COMPARTMENT WITHIN THE INTERCEPTOR OR SEPARATOR SHALL
BE 24 INCHES IN DIAMETER AND CONTAIN PICK HOLES. ALL COVERS SHALL BE CONSTRUCTED
OF CAST IRON OR EQUIVALENT TRAFFIC BEARING MATERIAL. MANHOLE COVERS MUST EXTEND
TO FINISH GRADE AND BE INSTALLED TO EXCLUDE THE ENTRANCE OF STORMWATER INTO THE
INTERCEPTOR OR SEPARATOR.
4. FULL SIZE DUAL SWEEP CLEANOUTS SHALL BE INSTALLED ON THE INLET AND OUTLET SIDES
OF THE INTERCEPTOR OR SEPARATOR.
5. INTERCEPTORS AND SEPARATORS MUST BE VENTED IN ACCORDANCE WITH THE NC STATE
PLUMBING CODE.
6. CONCRETE: 4000 P51 0 28 DAYS.
7. DESIGN: ACI 318 BUILDING CODE
ASTM C1613-06 FOR GREASE INTERCEPTORS
ASTM C913-02 FOR WATER AND WASTEWATER STRUCTURES
ASTM C890-06 FOR MINIMAL STRUCTURAL DESIGN LOADING
8. INTERCEPTORS AND SEPARATORS SHALL BE DESIGNED TO WITHSTAND AN H-20 WHEEL LOAD.
9. INTERCEPTORS OR SEPARATORS MADE OF POLYETHYLENE OR FIBERGLASS SHALL INCLUDE A
MINIMUM 12,000 P51 TENSILE STRENGTH, 19,000 P51 FLEXURAL STRENGTH, AND 800,000 PSI
FEXURAL MODULUS.
10. ALL INTERCEPTORS AND SEPARATORS SHALL BE INSTALLED IN ACCORDANCE WITH THE
MANUFACTURERS SPECIFICATIONS.
CITY OF RALEIGH
DEPARTMENT OF PUBLIC UTILITIES
DIMENSIONS: GREASE INTERCEPTORS
OIL -WATER -SAND SEPARATORS
DWG. NO. REVISIONS DATE REVISIONS DATE
S 41 RRH 3/9/00 D.H.L. 6/18/08
ABB 3/19/04
COVER 120 LBS. MINIMUM
BUTYL—NEK OR
APPROVED
SEALANT BETWEEN
FRAME AND
COVER
NOTES:
1) ALL MANHOLE FRAMES SHALL BE
DOMESTICALLY CAST.
2) FRAME SHALL BE A MINIMUM WEIGHT
OF 182 LBS. WITHIN PUBLIC ROW AND
160 LBS. WITHIN EASEMENTS.
3) COVER SHALL WEIGH A MIN. OF 120
LBS.
4) ALL MANHOLE FRAMES OUTSIDE OF
PAVED SURFACES SHALL BE BOLTED TO
THE CONE SECTION OR RING WITH A
MINIMUM OF 4 BOLTS PER FRAME.
MANHOLE FRAME AND COVER
5/8"X3" LAGSHIELD IN HOLE
DRILLED INTO CONE OR
RING WITH ANCHOR SUNK TO
DESIGN DEPTH, AND 3/8"X3"
HOT DIPPED GALVANIZED
LAG BOLT AND WASHER.
CITY OF RALEIGH
DEPARTMENT OF PUBLIC UTILITIES
STANDARD MANHOLE COVER
DWG. NO
S-25
REVISIONS DATE REVISIONS
3-1-87 3-1-87 A.B.B.
RRH 3-30-020.H.L.
DATE
2-9-05
6-18-08
ie
aui
Atiefirci
NC ENGINEERING
LICENSE NO. P-0803
S 01Z 0
F—CC0WW
WATER & SEWER SERVICE CONNECTION PLAN
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BUFFALOE RD.
RALEIGH, NORTH CAROLINA 27616
Drawn RLA
By
Checked us
By
DATE:
04/23/2021
REVISED:
1\27 APR 2021
PERMIT
DOCUMENTS
TRAFFIC
DETAILS
PLAN
Job
Code
SBBWS
Dwg No
S �C
3'0